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BIRTH CERTIFICATE APPLICATION Complete this form to order a certified copy of a Minnesota birth certificate.

The law requires you to provide information to order a birth certificate, Minnesota Statutes, section 144.225, subdivision 7, and Minnesota Rules, part 4601.2600. It is against the law to provide false information to get a birth certificate. You may be subject to fines, jail time or both. Minnesota Statutes, section 144.227 and section 609.02, subdivisions 3 and 4. Information to locate the requested birth record

Subj

ect

First name Middle name Last name Name suffix

Date of birth (mm/dd/yyyy)

☐ Female ☐ Male

City of birth County of birth

Pare

nts Parent one - first name Parent one - middle name Parent one - last name Last name before 1st marriage Name suffix

Parent two - first name Parent two middle name Parent two last name Last name before 1st marriage Name suffix

Person completing this application Requester name Requester date of birth (mm/dd/yyyy)

Requester mailing address – Street Apt/Unit # City State ZIP

Requester daytime phone Requester email

United Parcel Service (UPS) will not deliver to PO boxes or APO addresses. Information about birth certificates: Most Minnesota vital record information is public information. When a record is public, information and certificates are available to individuals who meet the legal requirements in items 1 - 19 below. Other vital record information is confidential. Data about the birth of a child to a woman who was not married to the child’s father when that child was conceived or born are confidential, unless the mother chooses to make the record public when the birth is registered. When a record is confidential, information and birth certificates are restricted to those persons listed below in items 20 – 24. MANDATORY — Check the boxes below that describe your relationship to the subject of the record: Birth certificates available to individuals who meet any of the legal requirements in items 1-19 below (Public records) 1. ☐ A parent named on the subject’s record 2. ☐ A grandparent of the subject 3. ☐ A great–grandparent of the subject 4. ☐ A child of the subject 5. ☐ A grandchild of the subject 6. ☐ A great-grandchild of the subject 7. ☐ Spouse of the subject (You must be the current spouse) 8. ☐ The subject of the vital record (I am requesting my own birth record) 9. ☐ Party responsible for filing the record (generally a health professional or birth attendant) 10. ☐ The legal custodian, guardian or conservator of the subject (a certified copy of a court order naming you is required) 11. ☐ The health care agent for the subject (health care power of attorney is required) 12. ☐ Subject’s personal representative; a certified copy is needed to administer the estate 13. ☐ Successor of the subject (subject is dead); the certified copy is needed to administer the estate 14. ☐ Determination or protection of a personal or property right and proof that birth certificate is needed 15. ☐ Adoption agency — to complete post-adoption search (Employee ID is required) 16. ☐ Local/state/federal governmental agency (Employee ID is required) 17. ☐ Attorney – my Minnesota Attorney License Number is:_______________________________ NON-Minnesota license? Affix a copy 18. ☐ Pursuant to a valid, certified copy of a U.S. court order (not a subpoena) releasing the certificate 19. ☐ I have a signed statement from a person above; it specifies the subject’s full name, date of birth, parents’ name, the signer’s relationship to the

subject of the record and it authorizes me to obtain the certificate. Birth certificates available only under the conditions or to the persons named below (Confidential records) 20. ☐ Parent named on the subject’s record 21. ☐ The legal custodian, guardian or conservator of the subject (a certified copy of a court order naming you is required) 22. ☐ The subject, when 16 years or older 23. ☐ Representatives of Minnesota programs that administer child support, medical assistance, MinnesotaCare, and services under Minnesota

Statutes, sections 124D.23 and 626.556. (Employee ID is required) 24. ☐ Pursuant to a valid, certified copy of a U.S. court order (not a subpoena) releasing the certificate

Signature and Notary (application must be signed in front of a notary if applying by mail or fax) I certify that the information provided on this application is accurate and complete to the best of my knowledge. Requester’s signature Notary Stamp/Seal

Signed or attested before me on: ______day of __________________, 20_

Notary public signature My commission expires